Dr. Pestana’s Surgery Notes THIRD EDITION Top 180 Vignettes for the Surgical Wards Ebook PDF download An airway is present if the patient is conscious and speaking in a normal tone of voice. The airway will soon be lost if there is an expanding hematoma or emphysema in the neck. An airway should be secured before the situation becomes critical.

An airway is also needed if the patient is unconscious (with a Glasgow Coma Scale of 8 or under) or his breathing is noisy or gurgly, if severe inhalation injury (breathing smoke) has occurred, or if it is necessary to connect the patient to a respirator. If an indication for securing an airway exists in a patient with potential cervical spine injury, the airway has to be secured before dealing with the cervical spine injury.

An airway is most commonly inserted by orotracheal intubation, under direct vision with the use of a laryngoscope, assisted in the awake patient by rapid induction with monitoring of pulse oxymetry, or less commonly with the help of topical anesthesia. In the presence of a cervical spine injury, orotracheal intubation can still be done if the head is secured and not moved. Another option in that setting is nasotracheal intubation over a fiber optic bronchoscope.

The use of a fiberoptic bronchoscope is mandatory when securing an airway if there is subcutaneous emphysema in the neck, which is a sign of major traumatic disruption of the Tracheobronchial tree. If for any reason (laryngospasm, severe maxillofacial injuries, an impacted foreign body that cannot be dislodged, etc.) intubation cannot be done in the usual manner and we are running out of time, a cricothyroidotomy may become necessary. It is the quickest and safest way to temporarily gain access before the patient sustains anoxic injury. Because of the potential need for future laryngeal reconstruction, however, we are reluctant to do it before the age of 12.